Comparison of older people with psychosis living in the community and in care homes

AIMS AND METHOD

To compare two groups of older people with chronic schizophreniaor delusional disorder living in the community and in carehomes, along the domains of morbidity suggested by prior research.From the case-load of one old age psychiatrist, 22 individualswith chronic psychosis residing in care homes were comparedto 23 living in their own homes. The measures used were: thePositive and Negative Symptom Score (PANSS; Kay et al, 1987);the Mini Mental State Examination (MMSE; Folstein et al, 1975);the Burvill Physical Illness Scale (Burvill et al, 1990);and an Activities of Daily Living Scale (IADL; Lawton et al,1969).

RESULTS

Those in care homes had significantly higher PANSS scores (38.9v. 21.0, P<0.01), largely accounted for by significantlymore deficit symptoms (14.2 v. 5.6, P<0.01). They also hadpoorer cognition and significantly greater impairment in daily-lifeactivities but their medical condition was not significantlyworse. Most were seen only by a psychiatrist.

CLINICAL IMPLICATIONS

The greater morbidity and disablement of older people with chronic schizophrenia or delusional disorder living in care homes islikely to be intrinsic to the disorder but does not appearto be taken into account in current service planning or delivery.

Introduction

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Introduction

The Royal College of Psychiatrists college report on individualswho enter old age with a psychosis such as chronic schizophrenia (Royal College of Psychiatrists, 2002) highlighted an unmetneed in this area and recommended local surveys to addressthis. One, undertaken in a Scottish service (McNulty et al, 2003), found high levels of disability and significant unmet needamong people with schizophrenia aged over 65 years old. Theseindividuals are often admitted to care homes but it is notknown in what way they differ from those who continue to residein their own homes. Factors known to contribute to morbidityin late-life psychosis include level of psychiatric symptomatology,cognition, medical morbidity and disablement (Jolley et al, 2004).In a single catchment area we compared these domains in twogroups of older people with either chronic schizophrenia ordelusional disorder, one in care homes and the other livingindependently in the community. The hypothesis we wanted totest was whether or not those in care homes would have greaterseverity of psychiatric symptoms, more medical morbidity andpoorer cognition than those living independently at home.

Method

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Method

Inclusion criteria were: aged over 65 years old, under the careof one psychiatrist (R.B.) who had a defined catchment area,a primary diagnosis of schizophrenia or delusional disorderaccording to ICD-10 criteria (World Health Organization, 1993)and living in the community. People excluded from our study were those with a primary diagnosis of dementia or affectivedisorder, in-patients of acute in-patient psychiatric unitsand those who refused to take part. Mental capacity and consentwas undertaken by R.B. Where a person lacked the capacity togive informed consent, their caregivers and/or relatives wereapproached. The research was approved by the local research ethics committee and Manchester Mental Health and Social CareTrust was the sponsor of the study.

We used the Positive and Negative Symptom Score (PANSS), whichassesses positive, negative and general psychotic symptomatologyon a 30-point scale (Kay et al, 1987). Cognition was assessedusing the Mini Mental State Examination (MMSE; Folstein et al, 1975) and dementia was diagnosed based on the ICD-10 criteria fordementia (World Health Organization, 1993). The Burvill PhysicalIllness Scale was used to quantify morbidity from physicalillness (Burvill et al, 1990) and the Instrumental Activitiesof Daily Living Scale (IADL; Lawton et al, 1969) was used toassess self-maintenance (6 categories, rated 0 or 1) and morecomplex daily-life tasks (8 categories, rated 0 or 1). Interviewswere conducted at the participant’s residence in compliancewith the Trust’s safe visiting policy. Sources of informationincluded the participant, caregivers and case notes.

The data was analysed using SPSS version 11.5 for Windows, with ${chi}$ ²-test for categorical data and t-test for continuous data.

Results

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Results

The inclusion criteria were met by 52 individuals. Four wereexcluded because they died or left the area before the studycommenced, two refused to take part and one was diagnosed ashaving psychotic depression rather than schizophrenia. Forty-fivepatients were therefore included, 23 living independently intheir own homes and 22 living in care homes. There were three specialist homes for the elderly mentally infirm (n=14) andthree residential homes (non-specialist, n=8).

Mean age was 74.3 years old, with 23 men and 22 women and withno significant age or gender differences between the groups (Table 1). The duration of illness ranged from 2 years to68 years, with mean of 22 years (16 years in own home-livinggroup and 30 years in residential home-living group, borderlinesignificance). In 78% of the participants, onset was at ageless than 65 years old, with no significant difference betweengroups. Three times as many (72% v. 28%, P<0.01) of thoseliving in care homes than those living in their own homes wereprescribed more than one psychotropic drug, but although higherby 22 mg, the calculated mean chlorpromazine equivalent dosage(using a formula by Woods, 2003) did not differ significantlybetween groups.

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Table 1. Differences between the two groups

Those in care homes had higher total PANSS scores but not onthe positive symptom sub-scale. Their daily-life activitieswere reduced across both basic and complex sub-scales. On theBurvill scale, medical morbidity did not differ between groups.Using the MMSE, cognition was significantly lower in the care home group but the overall rate of dementia defined clinically(ICD-10) did not differ.

Discussion

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Discussion

The strengths of the study are its delineation of all individualsfrom a single catchment area, low refusal rate and groups well-matchedby age. Its limitations include its small size and difficultyin generalising to other services. With these limitations,this study suggests markedly higher morbidity and disablementamong older people with chronic schizophrenia living in carehomes compared with those living in their own homes. However,the original hypothesis was only partly supported. Individualsin care homes had higher levels of psychiatric symptomatologybut this was largely from negative or deficit symptoms ratherthan positive ones. Their higher scores on the ‘general’sub-scale of the PANSS may have been owing to poorer cognitionas this sub-scale includes items such as disorientation and confusion. People in care homes had far greater impairmentin their daily-life activities, which included basic taskssuch as bathing, eating, toileting and food preparation aswell as more complex daily tasks. Four participants scored 0on the IADL scale, suggesting total reliance on carers for allof their needs. This disability was not accounted for by thosein care homes having more medical morbidity as we had hypothesised.Rather, the combination of deficit symptoms and poor cognitionappeared to be responsible. Poor cognition with or withoutdementia is reported in older people with schizophrenia (Harvey et al, 1999). Thus the disablement of care home residents seems likely tobe intrinsic to their psychotic disorder, although the effectsof long-term institutionalisation cannot be ruled out as anadditional factor.

There exists no national service framework that would adequatelyaddress the needs of older people with psychosis (Royal College of Psychiatrists, 2002).The two probably most relevant here are not directly concernedwith this group - the National Service Framework for Older People (Department of Health, 2001) focused on dementia and depression,and the National Service Framework for Mental Health (Department of Health, 1999)on adults of working age. Considering the complex handicaps arising from their disorder, detailed care planning and reviewby specialist psychiatric services are imperative for olderpeople with schizophrenia residing in care homes. Despite this,few of those in care homes that took part in this study receivedinput from any member of the Old Age Psychiatry Community MentalHealth Team other than the consultant, whereas a majority of those in their own homes received some input from those services.It is not known whether this is typical of other services ornot, but it warrants further research. What also need to beexamined are the pathways of entry into care homes among thispopulation group.

References

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